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122

Fig. 12.3 (a) Deployment of esophageal stent under uoroscopy. (b) Lateral view of esophageal

stent in nal position

• Gastroesophageal reux disease (GERD)

• Globus sensation

• Perforation

• Stent migration

Delayed complications occur months after the stent placement and include:

• Tumor ingrowth

• Stent migration

• Stent occlusion

• Development of esophageal stulae

• Recurrence of strictures [8]

Stent migration is the most common complication between early and delayed

categories. Placing an overlapping second stent can rectify partial migration. Fully

migrated stents can be endoscopically or surgically removed depending on stent

type, risk of perforation, and patient symptoms [6]. The future of esophageal stent-

ing will include stents for benign disease, prevention of GERD post-procedurally,

and potential biodegradability [5, 6].

Colonic Stenting

Colonic stenting is an emergency surgery for patients with colonic obstruction, 85%

of whom have colorectal cancer, which is associated with signicant morbidity and

mortality. Both temporary and permanent colostomies have a tremendous impact on

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the quality of life. Colonic stenting can offer a simpler, durable palliative solution

for patients with advanced disease in the left colon proximal to the rectum [9]. It can

also be a bridging therapy to surgery as recent literature showed short-term improve-

ments in patient outcomes without long-term disadvantages compared to surgical

colon resection [9, 10]. Fluoroscopic-guided colonic stenting is indicated in left-

sided lesions more than right-sided. Preparation involves performing a prior water-

based contrast enema for lesion localization.

Sedation with midazolam can be considered in high-anxiety or uncooperative

patients but is otherwise generally unnecessary. Prophylactic antibiotics in the form

of ciprooxacin and metronidazole can be administered at the physician’s discretion

as a single dose [9].

The patient is positioned supine or lateral decubitus. A guiding catheter is

advanced over a hydrophilic stiff guidewire thereby traversing the obstructed seg-

ment of colon. Once the catheter is positioned proximal to the obstruction, water-

soluble contrast is again injected to assess the risk of perforation under uoroscopy.

Surface skin radiopaque markers may be used if necessary for localization. Size and

delivery system for the stent are decided based upon anatomy visualized and then

deployed over the guidewire (Fig.12.4a–d). Margins of stent coverage should be

2cm proximal and distal to the respective ends of the obstruction [9].

Fig. 12.4 (a) Colonic stricture visualized. (b) Deployment of colonic stent under uoroscopy. (c)

Anteroposterior projection of colonic stent in nal position. (d) Lateral view of colonic stent in

nal position

12 Gastrointestinal Interventions

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Complications

• Minor complications include mild to moderate rectal bleeding, transient anorec-

tal pain, temporary incontinence, and fecal impaction.

• More severe complications include perforation, re-obstruction, stent migration,

and stent fracture [10, 11].

Acknowledgment We would like to thank Dr. Prasaanthan Gopee-Ramanan for his contributions

to this chapter (information given on rst page of chapter).

References

1. Lyon SM, Pascoe DM.Percutaneous gastrostomy and gastrojejunostomy. Semin Intervent

Radiol. 2004;21(3):181–9. https://doi.org/10.1055/s- 2004- 860876.

2. Dolan RS, Duszak R Jr, Bercu ZL, Martin JG, Newsome J, Kokabi N. Comparing the

safety and cost of image-guided percutaneous gastrostomy tube placement in the outpatient

versus overnight observation setting in a single-center retrospective study. Acad Radiol.

2021;28(8):1081–5.

3. Gerall C, Mencin AA, DeFazio J, Griggs C, Kabagambe S, Duron V. Primary gastrojeju-

nostomy tube placement using laparoscopy with endoscopic assistance: a novel technique. J

Pediatr Surg. 2021;56(2):412–6.

4. Johnson DY, Gallo CJ, Agassi AM, Sag AA, Martin JG, Pabon-Ramos W, etal. Percutaneous

gastrojejunostomy tubes: identication of predictors of retrograde jejunal limb migration into

the stomach. Clin Imaging. 2021;70:93–6.

5. Lowe AS, Sheridan MB.Esophageal stenting. Semin Intervent Radiol. 2004;21(3):157–66.

6. Hindy P, Hong J, Lam-Tsai Y, Gress F. A comprehensive review of esophageal stents.

Gastroenterol Hepatol (NY). 2012;8(8):526–34.

7. Acunas B, Rozanes I, Akpinar S, Tunaci A, Tunaci M, Acunas G. Palliation of malignant

esophageal strictures with self-expanding nitinol stents: drawbacks and complications.

Radiology. 1996;199:648–52.

8. Baron TH.Expandable metal stents for the treatment of cancerous obstruction of the gastroin-

testinal tract. N Engl J Med. 2001;344:1681–7.

9. de Gregorio MA, Mainar A, Rodriguez J, Alfonso ER, Tejero E, Herrera M, etal. Colon stent-

ing: a review. Semin Intervent Radiol. 2004;21(3):205–16.

10. Morino M, Arezzo A, Farnesi F, Forcignanò E.Colonic stenting in the emergency setting.

Medicina. 2021;57(4):328.

11. Harris G, Senagore A, Lavery I, Fazio V.The management of neoplastic colorectal obstruction

with colonic endolumenal stenting devices. Am J Surg. 2001;181:499–506.

A.-S. Fortier and P. Gopee-Ramanan

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Chapter 13

Hepatobiliary andPancreatic Interventions

EvaLiu andPrasaanthanGopee-Ramanan

Liver Biopsy

Image-guided biopsy of the liver is undertaken to obtain a tissue sample for patho-

logical diagnosis of a lesion initially identied on imaging. The indication for liver

biopsy is used for diagnostic clarication, staging, prognosis, and treatment guid-

ance. An inaccessible lesion, abnormal coagulopathy, or uncooperative patients are

all contraindications. The most common type of liver biopsy is percutaneous biopsy

where a thin needle is inserted, under ultrasound or computed tomography (CT)

guidance, and a small sample of tissue is removed for biopsy.

Patient Preparation

Preparation of the patient consists of:

• Obtaining informed consent, make sure to discuss the option of not having

the biopsy.

• Reviewing and correcting (if necessary) coagulation status. Standard transfusion

target include hematocrit ≥25%, platelet count >50 × 109/L, and brinogen

>120 mg/dL.

• Ensuring fasting for at least 2h prior.

E. Liu (*)

Michael G.DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada

e-mail: eva.liu@medportal.ca

P. Gopee-Ramanan

Department of Radiology, Michael G.DeGroote School of Medicine, Faculty of Health

Sciences, McMaster University, Hamilton, ON, Canada

e-mail: prasa.gopee@medportal.ca

Switzerland AG 2022

S. Athreya, M. Albahhar (eds.), Demystifying Interventional Radiology,

https://doi.org/10.1007/978-3-031-12023-7_13

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126

Complications from liver biopsy include:

• Hemorrhage

• AV stula formation

• Infection

• Biliary sepsis

Post-procedural care depends on the:

• Nature of the patient’s condition

• Location of the biopsy

• Complications encountered

• Coagulation status

Generally, vital signs are monitored every 15min for 1h, every 30min for the

next 2h, and every 2h after that until deemed ready for discharge. Analgesia may

be administered as needed. Most commonly, patients are advised bed rest for 2–3h,

and vital signs are monitored for the same duration.

Percutaneous Biliary Drainage andStenting

Indications andContraindications

• Indications for percutaneous biliary drainage and stenting (Fig. 13.1) include

obstructive jaundice as a result of malignant or benign biliary stricture or treat-

ment of cholangitis when ERCP or surgery is not possible.

• Ascites is a relative contraindication.

Fig. 13.1 (a) Percutaneous transhepatic biliary drainage and stent. (b) Percutaneous transhepatic

internal\external biliary drainage

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Procedure

Prophylactic single dose of antibiotics as per local policy is given. Under uoros-

copy or adjunct ultrasound guidance, local anesthetic is inltrated into the liver

capsule via approaching through the intercostal space above the tenth rib at the

midaxillary line. A Chiba (22G) needle is inserted and advanced under uoroscopy

toward the xiphisternum until it reaches the transverse process of the vertebral body.

After removing the central stylet, contrast medium is slowly injected while pulling

back on the needle until an intrahepatic duct is breached, and a swirling of bile and

contrast medium is visualized. Once the ductal location is conrmed, a guide wire

is advanced toward the CBD, the Chiba needle is removed, and a Ness set is intro-

duced over the wire. A hydrophilic wire is advanced through the Ness set and is

negotiated down the CBD.A larger 6–8F sheath is then inserted, injecting contrast

medium as needed to visualize the stricture. A 5Fr Kumpe (Cook) catheter might

be employed to negotiate the hydrophilic wire down the CBD and also across the

stricture. The hydrophilic wire is then exchanged for the Amplatz wire and then the

tract is dilated. An internal\external biliary drain or a biliary stent can then be left in

place [1].

Complications

Complications include:

• Bleeding

• Biliary peritonitis

• Sepsis [1]

Cholecystostomy Drainage

Percutaneous cholecystostomy decompresses the gallbladder under uoroscopic

guidance and/or ultrasound guidance (Fig. 13.2). This reduces symptoms and

inammation from acute cholecystitis. It is most useful in high-risk patients as a

bridging therapy to cholecystectomy [2]. The procedure is very similar to percuta-

neous biliary drainage and stenting discussed previously. The two options for

approach are transhepatic and transperitoneal, as dictated by patient condition and

anatomy. In the case of a transhepatic approach, care must be exercised to avoid

damage to the lung, pleura, or neurovascular bundle inferior to the rib. For the trans-

peritoneal approach, T-fasteners may be used to further anchor the gallbladder to the

wall, especially since it is expected that decompression over time will cause some

shifting of the gallbladder and drain. The procedure is ended with a cholecystogram

to ensure adequate drainage [2].

13 Hepatobiliary andPancreatic Interventions

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128

Fig. 13.2 Ultrasound image showing the pigtail cholecystostomy tube (arrow) within the

gallbladder

Transarterial Chemoembolization

Clinical Background

Hepatocellular carcinoma (HCC) is the most common primary liver malignancy and

sixth most common malignancy worldwide. Key risk factors include hepatitis B/C

infection (HBV/HCV), alcoholic liver damage, nonalcoholic steatohepatitis

(NASH), and exposure to aatoxin B1. The premise of TACE is to induce ischemia

of tumor bed and increase susceptibility or response to chemotherapeutic agents,

such as sorafenib.

Diagnosis

The current gold standard for HCC screening includes the HCC biomarker alpha-

fetoprotein (AFP) and ultrasonography on the basis of cost-effectiveness [3]. Levels

exceeding 400ng/mL (normal <10ng/mL) have an HCC positive predictive value

of 95% [4]. If suspicious nodules are detected, the American Association for the

Study of Liver Diseases (AASLD) recommendations are for liver nodules <1cm on

ultrasonography to be observed ultrasonographically every 3months until either

stability or growth of the lesion is established [5].

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Classication

TNM cancer staging is widely used for prognostic purposes in patients who can

undergo surgical resection or transplantation [5–7]. The Americas Hepato-

Pancreato- Biliary Association/American Joint Committee on Cancer (AHPBA/

AJCC) 2010 consensus statement recommends use of the Barcelona Clinic Liver

Cancer (BCLC) staging system in patients with advanced liver disease who are not

surgical candidates (Fig. 13.3) [8]. Liver Imaging and Reporting Data System

(LI-RADS) seeks to standardize imaging reports by radiology for HCC diagnosis

and staging [10].

Treatment Options

Current treatments for HCC available in interventional radiology include:

• Transarterial chemoembolization (TACE)

• Radiofrequency ablation (RFA)

• Cryoablation

Treatment decision for HCC is complicated due to the heterogeneity of the

disease, overlying liver disorders, and requires input from a multidisciplinary team

of hepatologists, interventional radiologists, medical oncologists, and surgical

oncologists.

BCLC Staging and Treatment Schedule

HCC

Stage 0

PST 0, Child-Pugh A

Very early stage (0)

Single <2 cm

Carcinoma in situ

Single

rtal pressure/bilirubin

Increased Associated diseases Po rtal invasion, N1, M1

Normal

Resection

Liver Transplantation

(CLT / LDLT)

Curative Treatments (30%)

5-year survival: 50-70%

Randomized controlled trials (50%)

3-year survival: 20-40%

Symptomatic ttc (20%)

1-year survival: 10-20%

PE/RF Chemoembolization

New

Agents

Ye s

3 nodules <3 cm

Early stage (A)

Single or 3 nodules <3 cm, PS 0

Intermediate stage (B)

Multinodular, PS 0

Advanced stage (C)

Portal invasion, N1, M1, PS 1-2

Terminal

stage (D)

Stage A-C

Okuda 1-2, PST 0-2, Child-Pugh A-B

Stage D

Okuda 3, PST >2, Child-Pugh

Fig. 13.3 BCLC staging and treatment schedule [8, 9]

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TACE

TACE involves injection of a cytotoxic drug such as doxorubicin that has been

emulsied radio-opaque agents followed by embolic agents (discussed more in

Chap. 9) into selective hepatic artery branches providing blood ow to a tumor [11].

TACE can be used to treat patients who do not meet criteria for resection and to

serve as a bridge therapy until transplant; it is the current standard for patients with

intermediate stage HCC. Drug-eluting beads (DEB) are embolic microspheres

loaded with cytotoxic drugs used to achieve sustained cytotoxicity. However, despite

the promise of DEB-TACE, randomized controlled trials have failed to show supe-

riority compared to conventional TACE in terms of patient survival, tumor response,

and safety [11]. Recent comparison of TACE-RFA with RFA alone has shown

improved survival in patients with HCC tumors less than 7 cm having received

TACE-RFA combination therapy [12]. Treatment allocation, tumor size, and tumor

number were signicant prognostic factors for overall survival, whereas treatment

allocation and tumor number were signicant prognostic factors for recurrence-free

survival [12].

Contraindications

Absolute contraindications include [13, 14]:

• Decompensated cirrhosis (Child-Pugh B or higher) including:

– Jaundice

– Clinical encephalopathy

– Refractory ascites

– Hepatorenal syndrome

• Extensive tumor with massive replacement of both lobes

• Severely reduced portal vein ow (e.g., non-tumoral portal vein occlusion or

hepatofugal blood ow)

• Technical contraindications to hepatic intra-arterial treatment (e.g., untreatable

arteriovenous stula)

• Renal insufciency (creatinine 2mg/dL or creatinine clearance 30mL/min)

Relative contraindications include [13, 14]:

• Tumor size >10cm

• Comorbidities involving compromised organ function:

– Active cardiovascular disease

– Active lung disease

• Untreated varices at high risk of bleeding

• Bile duct occlusion or incompetent papilla due to stent or surgery

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Common Embolic Agents

Temporary agents include Gelfoam, and permanent agents include particles (e.g.,

PVA), coils, and liquid agents (e.g., glue, onyx).

Treatment Outcomes

TACE is shown to improve median survival by 16–20 months [15], and use of

embolic drug-eluting beads (DEB) via TACE has improved the pharmacokinetics of

TACE and reduced systemic drug exposure [15]. DEB-TACE combination is cur-

rently being investigated [15].

Complications

Complications include:

• Access site injury

• Hepatic artery injury

• Pulmonary embolism

Imaging Required

Pre-procedure:

• Triple-phase computed tomography (CT) or magnetic resonance imaging (MRI)

of the liver

• Additional images as needed to rule out extrahepatic disease [15]

Radioembolization

The subdivision of interventional oncology under interventional radiology is seeing

a greater implementation of liver-directed therapies for management of unresect-

able primary and secondary liver tumors, colorectal cancers, and neuroendocrine

tumors. Treatment with radioembolization involves administering non-embolic

glass or resin microspheres containing radioactive yttrium-90. Under uoroscopic

guidance, once access to the vasculature feeding the tumor is achieved under uo-

roscopic guidance, the microspheres are slowly injected with intermittent contrast

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